This purpose of this talk is to overview the 2018 American Diabetes Association

Standards of Medical Care in Diabetes. These Standards comprise all of the current
and key clinical practice recommendations of the American Diabetes Association.

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S1 1
Moving on to section two, Classification and Diagnosis of Diabetes….

[SLIDE]

2
The 2018 Standards of Care classifies diabetes into four general clinical categories:

1. Type 1 diabetes, due to β-cell destruction, usually leading to absolute insulin

deficiency; [CLICK]
2. Type 2 diabetes, due to a progressive insulin secretory defect frequently on the
background of insulin resistance; [CLICK]
3. Gestational diabetes mellitus, which is diabetes diagnosed in the second or third
trimester pregnancy that is not clearly overt diabetes existing prior to gestation
[CLICK]
4. And other specific types of diabetes due to other causes, such as monogenic
diabetes syndromes, diseases of the exocrine pancreas (such as cystic fibrosis
and pancreatitis), and drug- or chemical-induced diabetes (such as diabetes
resulting from glucocorticoid use, treatment of HIV/AIDS, or medications used
after organ transplantation)

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S14 3
Fasting plasma glucose, the 2 hour plasma glucose after a 75-g oral glucose
tolerance test, and A1C are equally appropriate diagnostic tests for diabetes.

These diagnostic criteria are:

Fasting plasma glucose (FPG) ≥126 mg/dL

OR
2-hour plasma glucose ≥200 mg/dL during an OGTT
OR
A1C ≥6.5%
OR
In a patient with classic symptoms of hyperglycemia a random plasma glucose ≥
200 can also be used.

In the absence of unequivocal hyperglycemia, the result should be confirmed by

repeat testing.

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S15; Table 2
4
The 2018 Standards of Care additionally provide definitions for prediabetes.

An increased risk for diabetes/prediabetes is defined as:

Fasting plasma glucose (FPG) of 100-125 mg/dL

OR
2-hour plasma glucose of 140-199 mg/dL during an OGTT
OR
A1C between 5.7-6.4%

For all three tests, risk is continuous, extending below the lower limit of the
range and becoming disproportionately greater at the higher end of the range.

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S15; Table 2
5
As a result of recent evidence describing potential limitations in A1C
measurements due to hemoglobin variants, assay
interference, and conditions associated with red blood cell turnover, additional
recommendations were added to clarify
the appropriate use of the A1C test generally and in the diagnosis of diabetes in
these special cases
[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S14 6
Moving on to type 1 diabetes diagnosis and screening recommendations, these patients
often present with acute symptoms of diabetes and markedly elevated blood glucose
levels, and some cases are diagnosed with life-threatening ketoacidosis.

In these cases, knowing the blood glucose level is critical because, in addition to
confirming that symptoms are due to diabetes mellitus, this will inform management
decisions. Some providers may also want to know the A1C to determine how long a
patient has had hyperglycemia. Therefore the Association recommends that blood
glucose rather than A1c should be used to diagnose acute onset type 1 diabetes in those
with symptoms of hyperglycemia. [CLICK]

While there is currently a lack of accepted screening programs, consider referring

relatives of those with type 1 diabetes for antibody testing for risk assessment in the
setting of a clinical research study, which can be identified at diabetestrialnet.org.
[CLICK]

Persistence of two or more autoantibodies predicts clinical diabetes and may serve as an
indication for intervention in the setting of a clinical trial.

[SLIDE]
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S18
Imperatore G, Boyle JP, Thompson TJ, et al.; SEARCH for Diabetes in Youth Study Group. Projections of
type 1 and type 2 diabetes burden in the U.S. population aged <20 years through 2050: dynamic
modeling of incidence, mortality, and population growth. Diabetes Care 2012;35:2515–2520
Lipman TH, Levitt Katz LE, Ratcliffe SJ, et al. Increasing incidence of type 1 diabetes in youth: twenty years
of the Philadelphia Pediatric Diabetes Registry. Diabetes Care 2013;36:1597–1603
Pettitt DJ, Talton J, Dabelea D, et al. Prevalence of diabetes mellitus in U.S. youth in 2009: the SEARCH for
Diabetes in Youth Study. Diabetes Care. 16 September 2013 [Epub ahead of print] 7
And slide two of the screening recommendations for type 2 diabetes are again just like
those previously presented for prediabetes, and include:

• To test for type 2 diabetes, FPG, 2-h plasma glucose during a 75-g OGTT, and the A1C
are equally appropriate. B

• In patients with diabetes, identify and treat other cardiovascular disease risk factors.
B

• Testing for type 2 diabetes should be considered in children and adolescents who are
overweight or obese (BMI >85th percentile for age and sex, weight for height >85th
percentile, or weight >120% of ideal for height) and who have additional risk factors
for diabetes (Table 2.5). E

[SLIDE]

8
This new section highlights the importance of assessing comorbidities in the context of a
patient-centered comprehensive medical evaluation.
[SLIDE]

9
The table describing the components of a comprehensive medical evaluation
(Table
3.1) was substantially redesigned and reorganized for 2018, incorporating
information about the recommended frequency of the components of care at
both initial and follow-up visits.
Here is a section of the new table, regarding past medical and family history. The
table also includes sections on:

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S21; Table 7
10
--Social history
--Medications and Vaccinations

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S21; Table 7
11
--Technology Use
--Screening

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S21; Table 7
12
--Physical Examination

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S21; Table 7
13
--Laboratory Evaluation

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S21; Table 7
14
--And assessment and Planning

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S21; Table 7
15
We will now shift our discussion to Section 6: Glycemic Targets.

[SLIDE]

16
A1C reflects average glycemia over several months and has strong predictive value for
diabetes complications. Thus, A1C testing should be performed routinely in all patients
with diabetes—at initial assessment and as part of continuing care. Measurement about
every 3 months determines whether patients’ glycemic targets have been reached and
maintained, though the frequency of A1C testing should depend on the clinical situation,
the treatment regimen, and the clinician’s judgment.

For your patients meeting treatment goals and with stable control, check the A1C at
least twice a year, and for your patients whose therapy has changed or who aren’t
meeting glycemic goals, test quarterly. You may also have patients who are unstable or
highly intensively managed, such as pregnant women with type 1, whom you may wish
to test more frequently than every 3 months.

Point of care A1C testing can help accommodate more timely decisions, for example on
when to change therapy.

The A1C test is subject to certain limitations: conditions that affect erythrocyte turnover
(e.g., hemolysis, blood loss) and hemoglobin variants must be considered, particularly
when the A1C result does not correlate with the patient’s clinical situation; in addition,
A1C does not provide a measure of glycemic variability or hypoglycemia. For patients
prone to glycemic variability (especially type 1 diabetic patients, or type 2 diabetic
patients with severe insulin deficiency), glycemic control is best judged by the
combination of result of self-monitoring of blood glucose (SMBG) testing and A1C.
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S22–S23
Sacks DB, Arnold M, Bakris GL, et al. National Academy of Clinical Biochemistry. Position statement
executive summary: guidelines and recommendations for laboratory analysis in the diagnosis and
management of diabetes mellitus. Diabetes Care 2011;34:1419–1423
17
The A1C may also confirm the accuracy of a patient’s meter (or the patient’s reported
SMBG results) and the adequacy of the SMBG testing schedule

[SLIDE]

17
This slide shows the correlation between A1C and mean plasma glucose levels based on
data from the international A1C-Derived Average Glucose (ADAG) trial. The trial used
frequent SMBG and continuous glucose monitoring in 507 adults with type 1, type 2,
and no diabetes.

The Association and the American Association for Clinical Chemistry have determined
that the correlation (r = 0.92) is strong enough to justify reporting both an A1C result
and an estimated average glucose (eAG) results when a clinician orders the A1C test

• For patients in whom A1C/eAG and measured blood glucose appear discrepant,
clinicians should consider the possibilities of hemoglobinopathy or altered red
cell turnover, and the options of more frequent and/or different timing of SMBG
or use of CGM
• Other measures of chronic glycemia such as fructosamine are available, but
their linkage to average glucose and their prognostic significance are not as clear
as is the case for A1C

[CLICK]

• You can access a calculator for converting A1C results into eAG, in either mg/dL or
mmol/L, at professional.diabetes.org/eAG

[SLIDE]

References
Nathan DM, Kuenen J, Borg R, et al for the A1C-Derived Average Glucose Study Group. Translating the A1C
assay into estimated average glucose values. Diabetes Care 2008;31:1473–1478
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S23; Table 8
18
This slide, “Approach to Management of Hyperglycemia,” depicts the elements of
decision making used to determine appropriate A1C targets.

You may have seen this before, but in case you haven’t, we’ll walk through it briefly.
Going down the left side you see a series of patient or disease characteristics with a
corresponding target A1C impact scale on the right. The small end of the triangle
aligns with more stringent A1C targets and the fatter end aligns with less stringent A1C
targets. So taking the first one as an example, the red triangle: for patients at low risk
of hypoglycemia or other adverse drug effects, a more stringent A1C target may be
considered, while for those at higher risk, a less stringent A1C target is likely more
appropriate.

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S25; Figure 1
Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing glycemic targets in
type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med 2011;154:554–559
19
The patient and disease features are grouped into two categories, the top set consists of
factors that are usually not modifiable and the bottom set may be potentially
modifiable.

Where possible, decisions about A1C goals should be made in conjunction with the
patient, reflecting his or her preferences, needs, and values

[SLIDE]

19
Shown here are the Association’s recommended glycemic goals for many nonpregnant
adults with diabetes.

These recommendations are based on those for A1C values, with listed blood glucose
levels that appear to correlate with achievement of an A1C of <7.0%.

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S25–S26; Table 9
American Diabetes Association. Postprandial blood glucose. Diabetes Care 2001;24:775–778
Ceriello A, Taboga C, Tonutti L, et al. Evidence for an independent and cumulative effect of postprandial
hypertriglyceridemia and hyperglycemia on endothelial dysfunction and oxidative stress generation:
effects of short- and long-term simvastatin treatment. Circulation 2002;106:1211–1218
20
Here is the ADA’s new classification scheme for hypoglycemia, based on
recommendations from the International Hypoglycaemia Study Group. Of note,
this classification scheme considers a blood glucose less than 54 mg/dL (3.0
mmol/L) detected by SMBG, CGM (for at least 20 min), or laboratory
measurement of plasma glucose as sufficiently low to indicate serious, clinically
significant hypoglycemia that should be included in reports of clinical trials of
glucose-lowering drugs for the treatment of diabetes.

However, a glucose alert value of less than or equal to 70 mg/dL (3.9 mmol/L)
can be important for therapeutic dose adjustment of glucose-lowering drugs in
clinical care and is often related to symptomatic hypoglycemia.

Severe hypoglycemia is defined as severe cognitive impairment requiring

assistance from another person for recovery.

[SLIDE]

References
Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of Type I and Type II diabetes.
Diabetologia 2002;45:937–948
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S33–S34
21
Section 8: Pharmacologic Approaches to Glycemic Treatment

22
 Starting off with type 1 diabetes, there are plenty of other resources out there on
initiating and managing insulin therapy, so we won’t go into that here.
Most of your patients with type 1 diabetes should be treated with multiple dose
injections or insulin pump therapy. There are minimal differences between the two as far
as hypoglycemia is concerned. Whichever one a patient chooses, intensive management
and active patient or family participation should be strongly encouraged. [CLICK]

Most patients with type 1 diabetes should likewise use rapid-acting insulin analogs to
cover prandial needs to reduce the risk of hypoglycemia

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S26
The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of
diabetes on the development and progression of long-term complications in insulin-dependent
diabetes mellitus. N Engl J Med 1993;329:977–986
Nathan DM, Cleary PA, Backlund JY, et al for the Diabetes Control and Complications Trial/Epidemiology of
Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes
treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005;353:2643– 23
2653
Recommended pharmacological therapy for hyperglycemia in type 2 diabetes is
summarized on the next several slides.

First, metformin, if not contraindicated and if tolerated, is the preferred initial

pharmacological agent for type 2 diabetes. Metformin has a long-standing evidence base
for efficacy and safety, is inexpensive, and may reduce risk of cardiovascular events.
[CLICK]

To reflect new evidence showing an association between B12 deficiency and long
term metformin use, a recommendation was added in 2017 to consider periodic
measurement of B12 levels and supplementation as needed.

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S27
Inzucchi SE, Bergenstal RM, Buse JB, et al.; American Diabetes Association (ADA); European Association for
the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered
approach. Position Statement of the American Diabetes Association (ADA) and the European
Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364–1379 24
• Consider initiating insulin therapy (with or without additional agents) in patients with
newly diagnosed T2DM who are symptomatic and/or have A1C >10% and/or blood
glucose levels ≥300 mg/dL. E

• Consider initiating dual therapy in patients with newly diagnosed T2DM who have
A1C >9%. E

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S27
Inzucchi SE, Bergenstal RM, Buse JB, et al.; American Diabetes Association (ADA); European Association for
the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered
approach. Position Statement of the American Diabetes Association (ADA) and the European
Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364–1379 25
Multiple changes have been made to recommendations pertaining to the treatment of
patients with T2DM in 2018. Here we begin to see some of the substantive
recommendation changes:

• In patients without atherosclerotic cardiovascular disease (ASCVD), if monotherapy or

dual therapy does not achieve or maintain the A1C goal over 3 months, add an
additional antihyperglycemic agent based on drug-specific and patient factors (Table
8.1). A

• A patient-centered approach should be used to guide the choice of pharmacologic

agents. Considerations include efficacy, hypoglycemia risk, history of ASCVD, impact
on weight, potential side effects, renal effects, delivery method, cost, and patient
preferences. E

[SLIDE]
References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S27
Inzucchi SE, Bergenstal RM, Buse JB, et al.; American Diabetes Association (ADA); European Association for
the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered
approach. Position Statement of the American Diabetes Association (ADA) and the European
Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364–1379 26
 • In patients with T2DM and
established ASCVD,
antihyperglycemic therapy should
begin with lifestyle management and
metformin and subsequently
incorporate an agent proven to
reduce major adverse CV events and
CV mortality (currently empagliflozin
and liraglutide), after considering
drug-specific and patient factors. A

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S42 27
 • In patients with T2DM and
established ASCVD, after lifestyle
management and metformin, the
antihyperglycemic agent canagliflozin
may be considered to reduce major
adverse CV events, based on drug-
specific and patient factors. C
[SLIDE]

27
• Continuous reevaluation of the medication regimen and adjustment as needed to
incorporate patient factors (Table 8.1) and regimen complexity is recommended. E

• For patients with T2DM who are not achieving glycemic goals, drug intensification,
including consideration of insulin therapy, should not be delayed. B

• Metformin should be continued when used in combination with other agents,

including insulin, if not contraindicated and if tolerated. A

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S27
Inzucchi SE, Bergenstal RM, Buse JB, et al.; American Diabetes Association (ADA); European Association for
the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered
approach. Position Statement of the American Diabetes Association (ADA) and the European
Association for the Study of Diabetes (EASD). Diabetes Care 2012;35:1364–1379 28
Here is an overview of the ADA’s new treatment algorithm for type 2 diabetes, moving
from monotherapy, to dual therapy, to triple therapy, and then to combination injectable
therapy. Lifestyle management is emphasized throughout the progression of care, and
individualization based on efficacy, hypoglycemia risk, weight, side effects, and costs is
recommended.

It is important to note that the ADA’s full Standards of Care provides tables on the
properties of these agents, as well as the costs associated with them. Please visit
professional-dot-diabetes-org-slash-S-O-C for more information.

Let’s take a closer look at the algorithm.

[SLIDE]

29
The first step in the management of newly diagnosed type 2 diabetes is highlighted at
the top of the algorithm: initiate lifestyle management, set A1C target, and initiate
pharmacotherapy based on A1C at diagnosis.

For those with an initial A1C less than 9%, monotherapy may be considered, while those
with an A1C greater than 9% should consider dual therapy, and those with A1C greater
than 10%, high blood glucose (>300 mg/dl), or symptoms of hyperglycemia may
consider combination injectable therapy, which I’ll detail shortly.

The initial preferred agent remain metformin, though other therapies may be considered
if metformin is contraindicated or isn’t tolerated.

If A1C target is not achieved or maintained within 3 months, or at any point, lifestyle
management should be reinforced and dual therapy considered.

[SLIDE]

30
Starting with dual therapy, the algorithm has been updated this year to
incorporate consideration of ASCVD at the point of dual therapy given results of
recently published cardiovascular outcome trials.

As noted in the algorithm, in patients who do not have atherosclerotic

cardiovascular disease (ASCVD), consider a combination of metformin and any
one of the preferred six treatment options: sulfonylurea, thiazolidinedione, DPP-
4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist, or basal insulin; the choice of
which agent to add is based on drug specific effects and patient factors, as
highlighted in Table
8.1 which will be highlighted in the next slide.

For patients with ASCVD, add a second agent with evidence of cardiovascular risk
reduction after consideration of drug-specific and patient factors.

If A1C target is still not achieved after 3 months of dual therapy, proceed to a
three-drug combination. Again, if A1C target is not achieved after ~3 months of
triple therapy, proceed to combination injectable therapy. At each step, lifestyle
management should be reinforced and medication-taking behavior assessed.

[SLIDE]

31
As mentioned in the previous slide, Table 8.1 was added this year to highlight patient-
specific factors to consider when selecting antihyperglycemic treatments for adults with
T2DM.This is difficult to read, but I just wanted to highlight the overall structure of the
table and describe its contents. Considerations noted in the table include: efficacy,
hypoglycemia risk, effects on weight, cardiovascular effects, treatment cost, route of
administration, renal effects, and additional drug-specific considerations, such as
notable black box warnings and unique drug side effects.

[SLIDE]

32
The algorithm for combination injectable therapy in type 2 diabetes starts with
basal insulin, with or without other agents, and offers three equivalent strategies
for intensification if goals are not met, with ample room for individualization.

Again, it is important to note that the ADA’s full Standards of Care provides tables on the
properties of these agents, as well as the costs associated with them. Please visit
professional-dot-diabetes-org-slash-S-O-C for more information.

FBG, fasting blood glucose; GLP-1 RA, GLP-1 receptor agonist; hypo,
hypoglycemia.

[SLIDE]

33
Moving on to cardiovascular disease and risk management….

[SLIDE]

34
The following recommendations pertain to hypertension treatment goals:

• Most people with diabetes and hypertension should be treated to a systolic BP goal
of <140 mmHg and a diastolic BP goal of <90 mmHg. A [CLICK]

• Lower systolic and diastolic BP targets, such as 130/80 mmHg, may be appropriate
for individuals at high risk of CVD, if they can be achieved without undue treatment
burden. C [CLICK]

• In pregnant patients with diabetes and preexisting hypertension who are treated
with antihypertensive therapy, BP targets of 120-160/80-105 mmHg are suggested
in the interest of optimizing long-term maternal health and minimizing impaired
fetal growth. E [CLICK]

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 35
Recommendations in the area of lifestyle interventions to manage high blood pressure:

For patients with BP >120/80, lifestyle intervention consists of weight loss if overweight
or obese; a Dietary Approaches to Stop Hypertension-style dietary pattern including
reducing sodium and increasing potassium intake; moderation of alcohol intake; and
increased physical activity. B

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 36
The next three slides will be dedicated to recommendations on pharmacological
interventions for the treatment of hypertension. The 2018 recommendations are as
follows:

• Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in

addition to lifestyle therapy, have prompt initiation and timely titration of
pharmacologic therapy to achieve BP goals. A

• Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in

addition to lifestyle therapy, have prompt initiation and timely titration of two drugs
or a single-pill combination of drugs demonstrated to reduce CV events in patients
with diabetes. A

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 37
 Treatment for hypertension should include drug classes demonstrated to reduce CV
events in patients with diabetes: A

ACE Inhibitors

Angiotensin receptor blockers (ARBs)

Thiazide-like diuretics

Dihydropyridine calcium channel blockers

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 38
 Multiple-drug therapy is generally required to achieve BP targets. However,
combinations of ACE inhibitors and angiotensin receptor blockers and combinations
of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors
should not be used. A

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 39
 An ACE inhibitor or ARB, at the maximumly tolerated dose indicated for BP treatment,
is the recommended first-line treatment for hypertension in patients with diabetes
and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine A or 30-299 mg/g
creatinine. B If one class is not tolerated, the other should be substituted. B

For patients treated with an ACE inhibitor, ARB, or diuretic, serum

creatinine/estimated glomerular filtrated rate and serum potassium levels should
be monitored at least annually. B

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 40
And finally, for patients with resistant hypertension who are not meeting blood pressure
targets despite use of three classes of antihypertensive medications, inclusive of a
diuretic, the use of a mineralocorticoid receptor antagonist should be considered.

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 41
New to the standards in 2018, an algorithm summarizing recommendations for the
treatment of confirmed hypertension in people with diabetes has been added to Section
9.

A few key points about this algorithm is that it has different pathways depending on
blood pressure at hypertension diagnosis as well as the presence or absence of
albuminuria. It also emphasizes that ACE inhibitors and ARBs should not be combined.

[SLIDE]

42
Moving on to recommendations for lipid management. The following two
recommendations are provided in regard to lifestyle interventions.

• Lifestyle modification focusing on weight loss (if indicated); the reduction of

saturated fat, trans fat, and cholesterol intake; increase of dietary n-3 fatty acids,
viscous fiber, and plant stanols/sterols intake; and increased physical activity should
be recommended to improve the lipid profile in patients with diabetes. A

• Intensify lifestyle therapy and optimize glycemic control for patients with elevated
triglyceride levels (≥150 mg/dL) and/or low HDL cholesterol (<40 mg/dL for men, <50
for women). C

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 43
 • For patients with diabetes and ASCVD, if LDL cholesterol is ≥70 md/dL on maximally
tolerated statin dose, consider adding additional LDL-lowering therapy (such as
ezetimibe or PCSK9 inhibitor) after evaluating the potential for further ASCVD risk
reduction, drug-specific adverse effects, and patient preferences. Ezetimibe may be
preferred due to lower cost. A

• Statin therapy is contraindicated in pregnancy. B

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 44
The recommendations in Table 9.2 regarding statin and combination treatment in adults
with diabetes have been revised for 2018 to stratify risk based on whether a patient is
older or younger than 40 years of age and on whether a patient has ASCVD. For
example, patients of any age with ASCVD should be placed on a high-intensity statin.

[SLIDE]

45
Here’s a quick summary of recommended statin dosing for high and moderate intensity
therapy. Note that these are all based on once-daily dosing.

[SLIDE]

46
For patients with fasting triglyceride levels ≥500 md/dL, evaluate for secondary causes of
hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis.

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 47
In regard to other treatment combinations for the management of hyperlipidemia,

• Combination therapy (statin/fibrate) has not been shown to improve ASCVD

outcomes and is generally not recommended. A

• Combination therapy (statin/niacin) has not been shown to provide additional CV

benefit above statin therapy alone, may increase the risk of stroke with additional
side effects, and is generally not recommended. A

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S36 48
Aspirin has been shown to be effective in reducing cardiovascular morbidity and
mortality in high-risk patients with previous MI or stroke (secondary prevention). Its net
benefit in primary prevention among patients with no previous cardiovascular events is
more controversial, both for patients with and without diabetes.

Multiple recent well-conducted studies and meta-analyses reported a risk of heart

disease and stroke that is equivalent if not higher in women compared to men with
diabetes, including among non-elderly adults. Thus, the recommendations for using
aspirin as primary prevention are now revised to include both men and women aged 50
years or older with diabetes and one or more major risk factors, to reflect these more
recent findings.

Recommendations for the use of antiplatelet agents are summarized in two slides. The
2018 recommendations are as follows:

• Use aspirin therapy (75-162 mg/day) as a secondary prevention strategy in

those with diabetes and a history of ASCVD. A

• For patients with ASCVD and documented aspirin allergy, clopidogrel (75
mg/day) should be used. B
References
• Dual Diabetes
American antiplatelet therapy
Association. (withoflow-dose
Standards medical careaspirin and a P2Y12
in diabetes—2014. inhibitor)
Diabetes Care is
reasonable
2014;37(suppl for a year after an acute coronary syndrome A and may have
1):S40–S41
Pignone M, Alberts MJ, Colwell JA, et al.; American Diabetes Association; American Heart Association;
American College of Cardiology Foundation. Aspirin for primary prevention of cardiovascular events
in people with diabetes: a position statement of the American Diabetes Association, a scientific
statement of the American Heart Association, and an expert consensus document of the American
College of Cardiology Foundation. Diabetes Care 2010;33:1395–1402
49
 benefits beyond this period. B

[SLIDE}

49
Aspirin therapy (75-162 mg/day) may be considered as a primary prevention
strategy in those with type 1 or type 2 diabetes who are at increased CV risk. This
includes most men and women with diabetes aged ≥50 years who have at least
one additional major risk factor (family history of premature ASCVD,
hypertension, dyslipidemia, smoking, or albuminuria) and are not at increased
risk of bleeding. A

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S40–S41
Pignone M, Alberts MJ, Colwell JA, et al.; American Diabetes Association; American Heart Association;
American College of Cardiology Foundation. Aspirin for primary prevention of cardiovascular events
in people with diabetes: a position statement of the American Diabetes Association, a scientific
statement of the American Heart Association, and an expert consensus document of the American
College of Cardiology Foundation. Diabetes Care 2010;33:1395–1402
50
Recommendations for screening for coronary heart disease are summarized on this
slide:

The screening of asymptomatic patients with high ASCVD risk is not recommended, in
part because these high-risk patients should already be receiving intensive medical
therapy, an approach that provides similar benefit as invasive revascularization. There is
also some evidence that silent MI may reverse over time, adding to the controversy
concerning aggressive screening strategies
But do consider investigations for coronary artery disease in the presence of any of the
following:
Atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort)
Signs or symptoms of associated vascular disease including carotid bruits,
transient ischemic attack, stroke, claudication or peripheral arterial disease
EKG abnormalities (e.g. Q waves)

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S42 51
Recommendations for treatment of coronary heart disease are summarized on this and
the next slide:

[SLIDE]

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S42 52
 • In patients with T2DM and
established ASCVD,
antihyperglycemic therapy should
begin with lifestyle management and
metformin and subsequently
incorporate an agent proven to
reduce major adverse CV events and
CV mortality (currently empagliflozin
and liraglutide), after considering
drug-specific and patient factors. A

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S42 53
 • In patients with T2DM and
established ASCVD, after lifestyle
management and metformin, the
antihyperglycemic agent canagliflozin
may be considered to reduce major
adverse CV events, based on drug-
specific and patient factors. C
[SLIDE]

53
Moving onto section 10, Microvascular Complications and Foot Care.

[SLIDE]

54
Recommendations for screening patients with diabetic kidney disease are highlighted on
this slide. Diabetic kidney disease, or chronic kidney disease attributed to diabetes,
occurs in 20–40% of patients with diabetes and is the leading cause of end-stage renal
disease (ESRD). Kidney disease not attributable to diabetes, and due to other etiologies,
is referred to as chronic kidney disease (CKD).

Screening is recommended to occur at least once a year, assess urinary albumin (e.g.,
spot urine albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate
(eGFR) in patients with type 1 diabetes with duration of ≥5 years, in all patients with
type 2 diabetes, and in all patients with comorbid hypertension.

Reference
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care
2014;37(suppl 1):S42 55
The following series of slides will outline 2018 recommendations related to the
treatment of DKD. The recommendations are as follows:

• Optimize glucose control to reduce the risk or slow progression of DKD. A

• Optimize blood pressure control to reduce the risk or slow progression of DKD. A

• For people with nondialysis-dependent DKD, dietary protein intake should be ~0.8
g/kg body weight per day (the recommended daily allowance). For patients on
dialysis, higher levels of dietary protein intake should be considered. B

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl
1):S42–S43
The Diabetes Control and Complications (DCCT) Research Group. Effect of intensive therapy on the
development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial.
Kidney Int 1995;47:1703–1720
UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on
complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–865
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and 56
microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703–713
• In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor
or ARB is recommended for those with modestly elevated urinary albumin-to-
creatinine ratio (30–299 mg/g creatinine) B and is strongly recommended for
those with urinary albumin-to-creatinine ratio ≥300 mg/g creatinine and/or
eGFR <60 mL/min/1.73m2. A

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl
1):S42–S43
The Diabetes Control and Complications (DCCT) Research Group. Effect of intensive therapy on the
development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial.
Kidney Int 1995;47:1703–1720
UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on
complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–865
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and 57
microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703–713
• Periodically monitor serum creatinine and potassium levels for the development
of increased creatinine or changes in potassium when ACE inhibitors, ARBs, or
diuretics are used. B

• Continued monitoring of UACR in patients with albuminuria treated with an ACE

inhibitor or ARB is reasonable to assess the response to treatment and
progression of DKD. E

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl
1):S42–S43
The Diabetes Control and Complications (DCCT) Research Group. Effect of intensive therapy on the
development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial.
Kidney Int 1995;47:1703–1720
UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on
complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–865
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and 58
microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703–713
• An ACE inhibitor or an ARB is not recommended for the primary prevention of
DKD in patients with diabetes who have normal blood pressure, normal UACR
(<30 mg/g creatinine), and normal eGFR. B

• When eGFR rate is <60 mL/min/1.73m2, evaluate and manage potential

complications of DKD. E

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl
1):S42–S43
The Diabetes Control and Complications (DCCT) Research Group. Effect of intensive therapy on the
development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial.
Kidney Int 1995;47:1703–1720
UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on
complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–865
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and 59
microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703–713
• Patients should be referred for evaluation for renal replacement treatment if
they have an eGFR <30 mL/min/1.73m2. A

• Promptly refer to a physician experienced in the care of kidney disease for

uncertainty about the etiology of kidney disease, difficult management issues,
and rapidly progressing kidney disease. B

[SLIDE]

References
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014;37(suppl
1):S42–S43
The Diabetes Control and Complications (DCCT) Research Group. Effect of intensive therapy on the
development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial.
Kidney Int 1995;47:1703–1720
UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on
complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–865
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and 60
microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703–713
This table from the 2018 Standards of Care summarizes the stages of CKD and the
corresponding recommended foci of kidney-related care, as summarized in the
DKD recommendations just reviewed.

[SLIDE]

61
The prevalence of CKD complications correlates with eGFR. When eGFR is <60
mL/min/1.73m2, screening for complications of CKD is indicated (Table 10.2).

[SLIDE]

62
63
64